Provider Demographics
NPI:1538912134
Name:WILD TERRAIN THERAPY LLC
Entity type:Organization
Organization Name:WILD TERRAIN THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSMA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-22050
Authorized Official - Phone:480-798-2498
Mailing Address - Street 1:PO BOX 31853
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85046-1853
Mailing Address - Country:US
Mailing Address - Phone:480-721-9593
Mailing Address - Fax:
Practice Address - Street 1:11811 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1614
Practice Address - Country:US
Practice Address - Phone:480-721-9593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty